Provider Demographics
NPI:1629637392
Name:CCA NETWORK INC
Entity Type:Organization
Organization Name:CCA NETWORK INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SANDAL
Authorized Official - Middle Name:ARLILLIAN
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:702-255-0056
Mailing Address - Street 1:5836 S PECOS RD STE 102
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89120-3418
Mailing Address - Country:US
Mailing Address - Phone:702-255-0056
Mailing Address - Fax:702-255-0076
Practice Address - Street 1:5836 S PECOS RD STE 102
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89120-3418
Practice Address - Country:US
Practice Address - Phone:702-255-0056
Practice Address - Fax:702-255-0076
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-06
Last Update Date:2019-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
1699872614OtherNPPES
1760811798OtherNPPES